LUTHERAN HOME
Non profit - Corporation
54 Beds
Independent
Data: November 2025
Trust Grade
65/100
#286 of 913 in OH
Photo by Genacross Lutheran Services-Napoleon Campus
Photo by Leah Whitford
Photo by Phyllis Clemens
1 / 10 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Lutheran Home in Napoleon, Ohio has a Trust Grade of C+, indicating it is slightly above average, but not without its concerns. It ranks #286 out of 913 facilities in Ohio, placing it in the top half, and #2 out of 3 in Henry County, meaning there is only one other local option that is better. Unfortunately, the trend is worsening, with the number of identified issues increasing from 3 in 2023 to 8 in 2024. While staffing is a strong point with a perfect 5/5 rating, the turnover rate of 60% is concerning as it is higher than the state average. Recent inspector findings revealed that the facility failed to provide proper portions of food for residents, affecting all who receive meals, and that a physician did not attend important quarterly meetings, which could impact resident care. On a positive note, there have been no fines recorded, which suggests compliance with regulations.
- Trust Score
- C+
- In Ohio
- #286/913
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Ohio facilities.
- Skilled Nurses ✓ Good
- Each resident gets 43 minutes of Registered Nurse (RN) attention daily — more than average for Ohio. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 31%
No red flags
3 → 8 violations
★★★★☆
4.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 3 issues
2024: 8 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 60%
14pts above Ohio avg (46%)
Frequent staff changes - ask about care continuity
Staff turnover is elevated (60%)
12 points above Ohio average of 48%
The Ugly 41 deficiencies on record
Sept 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for oxygen use and upon discharge. This affected three (#15, #18, and #199) of 17 residents reviewed for MDS assessments. The facility census was 46.
Findings include:
1. Review of the medical record for Resident #18 revealed an admission date of 05/30/24 with diagnosis including chronic obstructive pulmonary disease (COPD).
Review of a physician order initiated 05/30/24 and discontinued 06/04/24 revealed Resident #18 was to receive oxygen therapy at two to four liters per minute (LPM) via nasal cannula (NC) every shift. The physician order initiated 06/04/24 and discontinued 08/05/24 revealed Resident #18 was to receive oxygen therapy at two to four LPM via NC every shift.
Review of the comprehensive MDS admission assessment dated [DATE] revealed Resident #18 did not receive oxygen therapy.
Interview on 09/04/24 at 3:32 P.M. with MDS Coordinator #184 confirmed the MDS assessment completed 06/06/24 for Resident #18 was coded incorrectly and should have reflected Resident #18 received oxygen therapy.
2. Review of the medical record for Resident #199 revealed he was admitted on [DATE], discharged to the hospital on [DATE], and returned to the facility on [DATE].
Review of a physician order initiated 08/16/24 and discontinued 08/29/24 revealed Resident #199 received oxygen via NC at two to three LPM every shift.
Review of the comprehensive MDS assessment, dated 08/23/24, revealed Resident #199 did not receive oxygen therapy.
Interview on 09/04/24 at 3:32 P.M. with MDS Coordinator #184 confirmed the MDS assessment completed 08/23/24 for Resident #199 was coded incorrectly and should have reflected Resident #199 received oxygen therapy.
3. Review of the medical record for Resident #15 revealed an admission date of 01/05/24 and discharged to the hospital on [DATE].
Review of the discharge MDS assessment dated [DATE] revealed Resident #15 discharged on 03/26/24. There was an additional MDS assessment dated [DATE] indicating a five-day MDS assessment was also completed on 03/26/24 and submitted on 04/08/24.
Interview 09/03/24 at 4:22 P.M. with MDS Coordinator #184 confirmed Resident t#15 discharged on 03/26/24 and did not return to the facility. MDS Coordinator #184 confirmed the five-day MDS assessment submitted on 04/08/24 was submitted in error.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to ensure a baseline care plan r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to ensure a baseline care plan reflected a resident's use of oxygen needs. This affected one (#199) of one resident reviewed for a baseline care plan. The facility census was 46.
Findings include:
Review of the medical record for Resident #199 revealed he was admitted on [DATE], discharged to the hospital on [DATE], and returned to facility on 08/29/24.
Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/23/24, revealed Resident #199 had impaired cognition.
Review of a physician order dated 08/29/24 revealed Resident #199 received oxygen at six liters per minute (LPM) via nasal cannula (NC) every shift.
Review of the baseline care plan for Resident #199 revealed nothing regarding his reliance on continuous oxygen therapy.
Interview on 09/05/24 at 11:31 A.M. with the Director of Nursing (DON) confirmed Resident #199's baseline care plan did not reflect his need for oxygen.
Review of the policy titled Comprehensive/Baseline Care Plan, reviewed 06/2023, revealed the baseline care plan would be the temporary working care plan until the comprehensive care plan was completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family and staff interviews, and review of the facility policy, the facility failed to ensu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family and staff interviews, and review of the facility policy, the facility failed to ensure oxygen was administered per physician order. This affected two (#18 and #199) of two residents reviewed for oxygen use. The facility census was 46.
Findings include:
1. Review of the medical record for Resident #18 revealed an admission date of 05/30/24 with diagnosis including chronic obstructive pulmonary disease (COPD).
Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 06/06/24, revealed Resident #18 had impaired cognition and did not reject care.
Review of a current physician order initiated 08/05/24 revealed Resident #18 was to receive oxygen therapy at two to four liters per minute (LPM) via nasal cannula (NC) every shift.
Observation on 09/03/24 at 1:54 P.M. revealed Resident #18 sitting in his wheelchair near the nurse's station. Resident #18's oxygen NC was applied and the oxygen tank gauge needle indicated the tank was empty.
Interview on 09/03/24 at 1:55 P.M. with Licensed Practical Nurse (LPN) #200 verified Resident #18's oxygen tank gauge indicated the tank was empty and needed to be replaced.
Observation on 09/04/24 at 7:49 A.M. revealed Resident #18 sitting in his wheelchair in the dining room. Resident #18 was wearing a NC connected to an oxygen tank in the carrier on the back of his wheelchair. Further observation revealed the oxygen tank gauge indicated the tank was empty.
Interview and observation on 09/04/24 at 7:50 A.M. with LPN #194 confirmed Resident #18's oxygen tank was empty. LPN #194 stated Resident #18 used approximately five tanks of oxygen daily.
2. Review of the medical record for Resident #199 revealed he was admitted on [DATE], discharged to the hospital on [DATE], and returned to facility on 08/29/24.
Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/23/24, revealed Resident #199 had impaired cognition.
Review of a physician order dated 08/29/24 revealed Resident #199 received oxygen at six LPM via NC every shift.
Interview on 09/03/24 at 11:16 A.M. with Resident #199's family member revealed she was concerned because she observed Resident #199 sitting in his recliner in his room while his oxygen NC remained on his bed. Resident #199's family stated they placed the NC on Resident #199.
Observation and interview on 09/05/24 at 7:31 A.M. with LPN #204 confirmed Resident #199 was lying in bed on his back and the NC was not in place. Further observation and interview with LPN #204 revealed Resident #199's NC was under him.
Interview on 09/05/24 at 7:33 A.M. with State Tested Nurse Aide (STNA) #196 revealed her shift began at 6:30 A.M. and she had not yet provided care to Resident #199.
Interview on 09/05/24 at 7:34 A.M. with STNA #205 revealed her shift began at 6:30 A.M. and she had not yet provided care to Resident #199.
Review of the policy titled Oxygen Administration, dated 07/2022, revealed oxygen was provided to facilitate breathing and oxygen should be provided at the prescribed amount.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interviews, and review of the facility policy, the facility failed to ensure th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interviews, and review of the facility policy, the facility failed to ensure the medical record reflected a change in condition. This affected one (#20) of 13 residents reviewed for medical record accuracies. The facility census was 46.
Findings include:
Review of the medical record for Resident #20 revealed a readmission date of 05/30/23 with diagnosis including dementia.
Review of the nursing progress notes dated 04/05/24 revealed a note dated 04/05/24 at 6:43 A.M. stating Resident #20 had a reddened area on her right hip and the physician was notified. The progress note dated 04/06/24 at 11:24 P.M. revealed Resident #20 was admitted to the hospital for bradycardia. There was no documentation of Resident #20 having a change in condition on 04/06/24, the physician being notified of the change in condition on 04/06/24, and the physician ordering to send Resident #20 to the emergency room on [DATE].
Review of the hospital records for Resident #20 revealed she was admitted to the Emergency Department (ED) on 04/06/24 at 5:25 P.M. and was discharged from the hospital on [DATE].
Review of a progress note dated 04/07/24 at 12:24 A.M. revealed Resident #20's hospital admitting diagnoses were updated to include altered level of consciousness, hypoglycemia, urinary tract infection, congestive heart failure, and medication effect.
Telephone interview on 09/03/24 at 2:51 P.M. with Resident #20's daughter revealed she was notified regarding Resident #20's 04/06/24 hospital admission.
Interview on 09/04/24 at 3:04 P.M. with the Director of Nursing (DON) confirmed Resident #20's electronic medical record contained no details regarding the change in condition leading to her hospitalization on 04/06/24. The DON further stated she would expect a progress note detailing the change in condition, including documentation regarding notification of the physician, and the order received to send the resident to the hospital, and notification of the resident's representative.
Review of the policy titled Notification of Resident's Condition, dated 04/2024, revealed completed notifications would be documented in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of immunization records, resident and staff interview, review of policy, and review of th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of immunization records, resident and staff interview, review of policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to offer the residents the COVID-19 vaccination per CDC recommendations. This affected three (#18, #29, and #45) of nine residents reviewed for COVID-19 vaccination. The facility census was 46.
Findings include:
1. Review of the medical record for Resident #18 revealed an admission date of 05/30/24 with diagnoses of chronic obstructive pulmonary disease (COPD) and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 06/06/24, revealed Resident #18 had impaired cognition.
Review of the immunization record, dated 09/05/24, revealed Resident #18 last COVID-19 vaccine was 10/03/22. There was no record of Resident #29 being offered the COVID-19 vaccination since admission.
Interview on 09/05/24 at 1:25 P.M. with Infection Preventionist #189 revealed new admission residents receive the vaccine upon request. Infection Preventionist #189 verified new admissions were not offered the COVID-19 or provided education. Infection Preventionist #189 verified Resident #18 was not offered or educated regarding the COVID-19 vaccination.
2. Review of the medical record revealed Resident #29 was admitted on [DATE]. Diagnoses type two diabetes mellitus with diabetic neuropathy and inflammatory disorders of scrotum. Review of the MDS assessment, dated 06/25/24, revealed the resident was cognitively intact.
Review of the immunization record, dated 06/28/24, revealed Resident #29 last COVID-19 vaccination was on 12/20/21. There was no record of Resident #29 being offered the COVID-19 vaccination since admission.
Interview on 09/05/24 at 1:29 P.M. with Resident #29 verified not being offered the COVID-19 vaccine.
Interview on 09/05/24 at 1:25 P.M. with Infection Preventionist #189 revealed new admission residents receive the vaccine upon request. Infection Preventionist #189 verified new admissions were not offered the COVID-19 or provided education. Infection Preventionist #189 verified Resident #29 was not offered or educated regarding the COVID-19 vaccination.
3. Review of the medical record revealed Resident #45 was admitted on [DATE]. Diagnoses included dementia. Review of the MDS assessment, dated 06/25/24, revealed the resident was severely cognitively impaired.
Review of the immunization record, dated 06/28/24, revealed Resident #45 last COVID-19 vaccination was on 12/20/21. There was no record of Resident #29 being offered the COVID-19 vaccination since admission.
Interview on 09/05/24 at 1:25 P.M. with Infection Preventionist #189 revealed new admission residents receive the vaccine upon request. Infection Preventionist #189 verified new admissions were not offered the COVID-19 or provided education. Infection Preventionist #189 verified Resident #45 was not offered or educated regarding the COVID-19 vaccination.
Review of the facility's Vaccination Policy, reviewed August 2023, revealed new, current residents and staff will be offered vaccines that aid in prevention infectious diseases unless the vaccine is medically contraindicated or the resident or staff member has already been vaccinated.
Review of the CDC guidance titled Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States, updated 08/23/24 and located at https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html, revealed the CDC recommends that people receive all recommended COVID-19 vaccine doses. Vaccination is especially important for people at highest risk of severe COVID-19, including people ages 65 years and older; people with underlying medical conditions, including immune compromise; people living in long-term care facilities; and pregnant people to protect themselves and their infants.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, and review of the menu spreadsheets, the facility failed to ensure residents received proper portions of protein and vegetables. This affected all 46 residents i...
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Based on observation, staff interview, and review of the menu spreadsheets, the facility failed to ensure residents received proper portions of protein and vegetables. This affected all 46 residents in the facility who receive food from the kitchen. Additionally, the facility failed to ensure residents on a pureed diet received proper portions of carbohydrate. This affected six (#2, #7, #19, #20, #32, and #36) residents identified on a pureed diet. The facility census was 46.
Findings include:
1. Observation on 09/04/24 at 11:45 A.M. revealed [NAME] #157 taking temperatures of noon menu items. The chicken Philly sandwiches were already prepared with chicken, onion, and peppers portioned into the bun. Concurrent interview with [NAME] #157 stated another staff prepared the sandwiches.
Interview on 09/04/24 at 11:52 A.M. with Dietary Manager (DM) #183 revealed the facility used an outside company to provide menus and spreadsheets. DM #183 stated the facility began with a new company in May 2024 and the new menus did not provide portion sizes on the spreadsheets; therefore, DM #183 did not know what portion of chicken and vegetables to provide in the chicken Philly sandwich.
Interview on 09/04/24 at 12:03 P.M. with Dietary Aide (DA) #161 revealed she prepared the chicken Philly sandwich. DA #161 stated she grilled chicken slices, onions, and peppers together, then used a four-ounce scoop to portion the chicken-vegetable mixture into buns. DA #161 stated if the scoop seemed to have more vegetables than meat, she would sometimes add extra chicken to the sandwich.
Interview and observation on 09/04/24 at 12:07 P.M. with [NAME] #157 revealed she already pre-portioned the cucumber salad into plastic containers. [NAME] #157 stated she used a two-and-two-thirds cup scoop to portion the cucumber salad.
Observation of meal service on 09/04/24 beginning at 12:14 P.M. revealed [NAME] #157 serving one sandwich and one portion of cucumber salad to residents on a regular diet. Further observation revealed [NAME] #157 served one sandwich, with ground chicken and vegetables, with peas and carrots to residents on a mechanical soft diet, and served pureed soup, a pureed sandwich, and pureed chicken and vegetables to residents on a pureed diet.
Observation and interview on 09/04/24 at 12:38 P.M. with [NAME] #157 revealed meal service was complete. [NAME] #157 verified the scoops she used during service were a three-and-one-fourth ounce scoop for pureed soup, a three-and-one-fourth ounce scoop for pureed sandwich, and a two-and-two-thirds ounce scoop for peas and carrots, and pureed peas and carrots.
Interview on 09/04/24 at 12:40 P.M. with DM #183, with concurrent review of the menu and recipes revealed the chicken Philly sandwich should have included three ounces of chicken. Additionally, the recipe did not include peppers or onions. DM #183 confirmed she could not verify residents received three ounces of chicken in their sandwiches due to DA #161 using a four-ounce scoop to portion chicken mixed with onions and peppers.
Further review of the menu with DM #183 revealed the cucumber salad portion should have been four ounces rather than the two-and-two-thirds ounces provided. There was no guidance for portions sizes or preparation methods for mechanical soft or pureed items.
Follow-up interview on 09/04/24 at approximately 3:30 P.M. with DM #183 revealed she received a spreadsheet with portion sizes for mechanical soft and pureed menu items from the outside company who provided their menus. Concurrent review of the menu spreadsheet revealed residents on a mechanical soft diet should have received one chicken Philly sandwich with ground meat and four ounces of soft cucumber salad. DM #183 again confirmed she could not verify the portion of protein provided in the mechanical soft chicken Philly sandwich, and confirmed residents on a mechanical soft diet did not receive four ounces of cucumber salad, or four ounces of alternative vegetable.
The spreadsheet revealed residents on a pureed diet should receive six ounces of pureed vegetable garden soup, four ounces of pureed chicken Philly cheesesteak and four ounces of pureed cucumber salad. DM #183 confirmed no recipe was provided for pureed chicken Philly cheesesteak and therefore she could not verify what portion of protein or carbohydrate residents on a pureed diet should have received. Additionally, DM #183 confirmed residents on a pureed diet did not receive four ounces of vegetables.
2. Observation and interview on 09/04/24 at 10:04 A.M. revealed [NAME] #157 preparing pureed chicken Philly sandwich for six residents on a pureed diet for the noon meal. [NAME] #157 placed a large, unmeasured portion of grilled chicken, onions, and vegetables with two sandwich rolls into the blender. [NAME] #157 used cheese sauce to thin the mixture to an appropriate consistency. [NAME] #157 confirmed she used two rolls for six residents to help thicken the mixture.
Observation after meal service was completed on 09/04/24 at 12:38 P.M. revealed some pureed chicken/vegetable/bread mixture remained in the pan.
Interview and concurrent review of the menu, spreadsheet, and recipes with DM #183 on 09/04/24 at approximately 3:30 P.M. confirmed she did not have a recipe for preparing pureed chicken Philly sandwich and could not verify residents on a pureed diet were served the appropriate portions of carbohydrate. Additionally, DM #183 confirmed the pureed preparation made by [NAME] #157 with an unmeasured amount of chicken and vegetables with two rolls was not adequate to provide the expected portion of one roll per person.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0730
(Tag F0730)
Minor procedural issue · This affected most or all residents
Based on personnel file review and staff interview, the facility failed to ensure one of four State Tested Nursing Assistants (STNA) received an annual performance review. This had the potential to af...
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Based on personnel file review and staff interview, the facility failed to ensure one of four State Tested Nursing Assistants (STNA) received an annual performance review. This had the potential to affect all 46 residents residing in the facility.
Findings include:
Review of the personnel file of STNA #195 revealed a hire date of 05/19/23. The file was absent of any yearly performance review having been completed.
Interview on 09/05/24 at 11:00 A.M. with Human Resources #202 verified there was no yearly performance review completed for STNA #195.
Apr 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interview, and facility policy review the facility failed to notify the family ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interview, and facility policy review the facility failed to notify the family of a residents change of condition and transfer to local hospital for evaluation and treatment of stroke symptoms. This affected one resident (#44) reviewed for notification of change of condition. The facility census was 48.
Findings include:
Review of the medical record for Resident #44 revealed a re-admission date of 01/23/24 with a diagnosis of cerebral infarct (stroke).
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact.
Review of the facility form titled HIPAA/PHI Authorization and Consent Form dated 12/23/23 from admission revealed Resident #44 identified his brother as his emergency contact.
Review of the nursing progress noted dated 01/13/24 at 3:23 P.M. for Resident #44 revealed the nurse was called to the resident's room and was noted to have right sided facial droop. Resident #44 complained of feeling right sided numbness and tingling. Resident #44 was able to move his right hand some and able to squeeze with both hands. Vital signs for Resident #44 revealed a blood pressure of 171/95 millimeters of mercury (mm/Hg), a pulse of 90 beats per minute, a respiratory rate of 18 breaths per minute, and his oxygen saturation was 95%. The nurse called on-call physician for Resident #44's primary physician and left a message. The nurse then called the emergency number 911 on 01/13/24 at 9:00 A.M. two Emergency Medical Services (EMS) personnel arrived, and Resident #44 was transported to the nearest hospital for evaluation and treatment.
Review of the nursing progress notes revealed no documentation of notification of the family or representative for Resident #44 following discharge from the facility for a change in medical condition.
Interview on 04/22/24 at 2:15 P.M. with a family member of Resident #44 revealed the facility did not contact any family member regarding the transfer to the hospital for a change of condition.
Interview on 04/22/24 at 3:40 P.M. with the Director of Nursing (DON) verified the family for Resident #44 was not notified of change of condition or transfer to hospital for stroke symptoms.
Review of the facilities policy titled Notification of Residents Condition revised 09/20 revealed the facility will notify POA or representative will be notified by nursing when there is a significant change in the residents physical, mental, or psychological status.
This deficiency represents non-compliance investigated under Complaint Number OH00152599.
Dec 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and review of policy, the facility failed to safely transfe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and review of policy, the facility failed to safely transfer a resident using a mechanical lift device. This directly affected one (#48) of three residents reviewed for assistance with transfers. The facility identified five additional residents (#14, #21, #41, #45, and #49) utilizing a mechanical lift devices. The facility census was 48.
Findings include:
Review of the medical record of Resident #48 revealed an admission date of 08/10/22. Diagnoses include chronic obstructive pulmonary disease, rheumatoid arthritis, type II diabetes mellitus, venous insufficiency, and neuromuscular dysfunction of bladder.
Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance for activities of daily living and transfers.
Review of the care plan dated 08/19/22 revealed an intervention for falls to include the use of a stand-up lift. A second intervention dated 08/19/22 for basic needs revealed a mechanical lift to assist with transfers, type: total lift.
Review of the progress note dated 11/22/23 at 6:53 A.M., revealed Resident #48 was being transferred to a reclining chair, by State Tested Nursing Assistants (STNA), using a mechanical lift device. Resident #48 was suspended over the recliner when the device tipped over onto Resident #48. An ice pack was applied, and pain medications administered. A second note at 11:13 A.M., revealed Resident #48 continued to have a knot on her forehead and remained alert with pupils equal, round, and reactive to light, hand grasp and pedal push equal. A note dated 11/24/23 at 6:33 A.M., revealed bruising noted to right forehead and below right eye with pain upon palpation or moving eyebrows.
Interview on 12/18/23 at 9:00 A.M., with Resident #43 revealed she had fallen from the mechanical lift some time ago. Resident #43 stated she fell into her recliner and had a black eye and bruise on her forehead. Resident #48 stated the lift had not been used properly but didn't feel as if the staff had done it on purpose.
Interview on 12/18/23 at 9:05 A.M., with Assistant Director of Nursing (ADON) #151 revealed Resident #48 was moved to a bigger room to safely use the mechanical lift. The lift went to tip and the aides tried to hold it. Both STNAs were adamant the legs were completely open, one STNA in front and one working the lift. The mechanical lift was pulled immediately from use and the maintenance staff inspected the lift and found nothing wrong. The investigation revealed no definite conclusion as to how the lift tipped, possibly the legs were not completely opened to ensure a stable base. Both STNAs were agency. The agencies were all alerted to ensure STNAs received education on the use of mechanical lifts.
Review of a typed statement from the Administrator after talking with agency STNA #145 revealed Resident #48 was almost over to the recliner when the lift tipped onto resident.
Review of the policy titled, Mechanical Lift dated May 2023, revealed one step to include widen the legs of the lift and raise the resident to a level high enough to perform a safe transfer. Once the resident is raised, close the legs of the lift, and carefully move the lift to transfer the resident to the desired location such as a chair. Lower the lift to properly position the resident.
This deficiency represents non-compliance investigated under Complaint Number OH00149183.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, review of facility resident list, staff interview and policy review, the facility failed to ensure medications were properly stored when a medication cart was left with a drawer ...
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Based on observation, review of facility resident list, staff interview and policy review, the facility failed to ensure medications were properly stored when a medication cart was left with a drawer open, the cart unlocked, and unattended. This had the potential to affect two residents (#33 and #34) identified as being independently mobile and confused. The facility census was 48.
Findings include:
Observation and interview on 12/14/23 at 7:39 A.M., the medication cart was unlocked, the top drawer was open, medications were visible and no staff was in attendance. Licensed Practical Nurse (LPN) #100 exited the room of Resident #37 and verified the cart was unattended and unlocked.
Review of a facility identified list revealed two residents (#33 and #34) are independently mobile and have confusion.
Review of the policy titled Security of Medication Cart dated 04/12 revealed the medication cart is to be locked when out of view of the nurse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, review of facility resident list and review of policy, the facility failed to ensure the shared glucometer was disinfected between residents. The facility furthe...
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Based on observation, staff interview, review of facility resident list and review of policy, the facility failed to ensure the shared glucometer was disinfected between residents. The facility further failed to ensure the correct disinfecting solution was used to cleanse the glucometer. This had the potential to affect two residents (#36 and #37) identified as using the glucometer. The facility census was 48.
Findings include:
Observation on 12/14/23 at 7:39 A.M., revealed Licensed Practical Nurse (LPN) #100 was carrying a glucometer when exiting the room of Resident #37. LPN #100 proceeded into the room of Resident #36 with the glucometer and proceeded to perform a fingerstick to obtain a blood glucose reading. LPN #100 had not disinfected the meter between residents.
Interview with LPN #100, at the time of the observation verified not having disinfected the glucometer between resident use.
Continued observation revealed LPN #100 was using an alcohol prep pad to clean the glucometer; after this surveyor questioned her about not cleaning the meter between residents and thought that was an acceptable cleanser.
Review of a facility identified list revealed two residents (#36 and #37) utilize a glucometer.
Review of the policy titled, Disinfecting Glucometer's and other reusable patient equipment dated May 2020 revealed the glucometer is to be cleansed between residents using sanitary wipe.
Jun 2022
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
Based on review of personal fund accounts, observation, resident and staff interview, and review of facility policy, the facility failed to ensure residents had access to personal funds. This affected...
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Based on review of personal fund accounts, observation, resident and staff interview, and review of facility policy, the facility failed to ensure residents had access to personal funds. This affected one (#39) out of 26 residents with personal fund accounts. The facility census is 58.
Findings include:
Review of the personal fund accounts revealed Resident #39 had an account managed by the facility. Review of the most recent quarterly statement revealed as of 06/27/22 Resident #39's remaining balance was $29.95.
Observation on 06/27/22 at 12:27 P.M. revealed Resident #39 requested $10 of personal funds from Activities Assistant #429. Activities Assistant #429 asked numerous questions to Resident #39 of why she needed the money and what she planned to purchase. Resident #39 avoided the question for a couple of instances and made a short joking remark. Activities Assistant #429 stated the Business Office Manager was out that day and Resident #38 could not obtain her funds until tomorrow. Medical Records Clerk #432 offered to loan Resident #39 $10 until the next day.
Interview on 06/27/22 at 12:30 P.M. with Resident #39 verified she was told she could not access $10 from her account because the Business Office Manager was out of the building.
Interview on 06/27/22 at 1:31 P.M. with Activities Assistant #429 verified telling Resident #39 the Business Office Manager was out of the office and she could not access her money. Activities Assistant #429 reported Resident #39 had an appointment with transportation and often attempts to get the driver to stop so she can purchase candy. Activities Assistant #429 reported Resident #39 has diabetes and should not eat candy.
Interview on 06/30/22 at 10:53 A.M. with Business Office Manager #434 verified she was not working on 06/27/22. Business Office Manager #434 stated there is a process in place to ensure residents have access personal funds at all times, even when she is out of the office.
Review of the facility policy titled Resident Funds, revised June 2020, revealed the facility will provide a means for the resident to access his or her funds.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide priv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide privacy when clipping a resident's toe nails for one (#313) resident randomly observed. The facility census was 58.
Findings include:
Review of the medical record revealed Resident #313 was admitted on [DATE]. Diagnosis included Alzheimer's disease, major depressive disorder, and dementia.
Observation on 06/28/22 at 10:55 A.M. revealed Licensed Practical Nurse (LPN) #455 clipping Resident #313's toe nails in the resident common area. Residents also present in the common area included Resident #8, #22, #34, #35, #40, #56, and #59.
Interview on 06/28/22 at 11:11 A.M. with Licensed Practical Nurse (LPN) #455 verified clipping Resident #313's toe nails in the common area.
Review of facility policy titled Quality of Life, created on 11/13/17, revealed the resident shall be cared for in a manner that is respectful and dignified in recognition of their individuality.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review, resident interview, staff interview and review of the facility policy, the facility failed report to the State Survey Agency an allegation when a resident intentionally poured ...
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Based on record review, resident interview, staff interview and review of the facility policy, the facility failed report to the State Survey Agency an allegation when a resident intentionally poured water onto a confused resident. This affected two (#39 and #54) out of 45 residents reviewed for abuse. The current census is 58.
Findings include:
Review of Resident #39's medical record revealed an admission dated of 07/11/19. Diagnoses included borderline personality disorder, type two diabetes mellitus, major depressive disorder, peripheral vascular disease, osteoarthritis, hyperlipidemia, insomnia, epilepsy, and hypertension.
Review of the Minimum Data Set (MDS) assessment, dated 05/09/22, revealed the resident was cognitively intact.
Review of Resident #39's progress notes revealed the record was silent of any resident to resident interactions.
Interview on 06/27/22 at 9:24 A.M., Resident #39 stated Resident #54 had wandered into her room, but she had not come back since dumping a cup of water on her. Resident #39 stated about two to three weeks ago Resident #54 came into her room and Resident #39 had told her to leave repeatedly. Resident #39 stated Resident #54 would not leave and continued to state she wanted a shower. Resident #39 stated she gave her what she wanted by sprinkling Resident #54 with water then dumping the rest of the cup of water on Resident #54. Resident #39 reported facility staff were upset with her at the time for dumping water on another resident and she was instructed to next time use her call light.
Review of Resident #54's medical record revealed an admission dated of 02/21/17. Diagnoses includes anoxic brain damage, type two diabetes, irritability and anger, violent behavior, cognitive communication deficit, and unsteadiness on feet.
Review of the MDS assessment, dated 05/21/22, revealed the resident was severely cognitively impaired.
Review of Resident #54's progress note, dated 05/27/22 at 4:59 P.M., revealed the resident was intermittently wandering the unit and at times attempting to go into other resident rooms. One on one redirection and frequent toileting attempts with minimal success were attempted to prevent wandering into other rooms. Staff monitoring resident to attempt to prevent incident.
Interview on 06/28/22 at 3:19 P.M. with State Tested Nursing Assistant (STNA) #422 verified hearing about an incident between Resident #39 and Resident #54 about two to three weeks ago.
Interview on 06/28/22 at 3:26 P.M. with Resident #54 revealed the resident had no recollection of the incident.
Review of Self-Reported Incidents (SRI) for 2022 revealed no SRI had been initiated regarding a resident to resident altercation between Resident #39 and Resident #54.
Interview on 06/29/22 at approximately 12:00 P.M. with the Administrator and Registered Nurse (RN) Regional Nurse #456 verified they were aware of an interaction between Resident #39 and #54 on an unknown date when Resident #39 splashed water on Resident #54. RN Regional Nurse #456 reported the Director of Nursing (DON) called the Administrator who had called RN Regional Nurse #456. They determined a self-reported incident was not required because there was no intent to harm.
Interview on 06/29/22 at 3:10 P.M. with Licensed Practical Nurse (LPN) #435 verified on 05/26/22 Resident #39 dumped approximately 120 cubic centimeter (cc) of water on Resident #54 after she would not leave her room and repeatedly stated she wanted a shower. LPN #435 reported water was observed on Resident #54 shirt near the waistband. LPN #435 reported neither resident was upset about the incident and Resident #39 laughed. LPN #435 stated she did believe it was a resident to resident incident and called the on-call manager to report the concern.
Review of policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, reviewed 02/2021, revealed the definition of abuse includes the willful infliction of intimidation or punishment with resulting physical harm, pain or mental anguish. It includes mental abuse. The definition of willful meant the individual must have acted deliberately, not that the individual intended to inflict injury or harm. The an allegation of abuse should be reported to the Ohio Department of Health (ODH) immediately, but not later than twenty four hours after the allegation is made.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review, resident interview, staff interview and review of the facility policy, the facility failed investigate an allegation when a resident intentionally poured water onto a confused ...
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Based on record review, resident interview, staff interview and review of the facility policy, the facility failed investigate an allegation when a resident intentionally poured water onto a confused resident. This affected two (#39 and #54) out of 45 residents reviewed for abuse. The current census is 58.
Findings include:
Review of Resident #39's medical record revealed an admission dated of 07/11/19. Diagnoses included borderline personality disorder, type two diabetes mellitus, major depressive disorder, peripheral vascular disease, osteoarthritis, hyperlipidemia, insomnia, epilepsy, and hypertension.
Review of the Minimum Data Set (MDS) assessment, dated 05/09/22, revealed the resident was cognitively intact.
Review of Resident #39's progress notes revealed the record was silent of any resident to resident interactions.
Interview on 06/27/22 at 9:24 A.M., Resident #39 stated Resident #54 had wandered into her room, but she had not come back since dumping a cup of water on her. Resident #39 stated about two to three weeks ago Resident #54 came into her room and Resident #39 had told her to leave repeatedly. Resident #39 stated Resident #54 would not leave and continued to state she wanted a shower. Resident #39 stated she gave her what she wanted by sprinkling Resident #54 with water then dumping the rest of the cup of water on Resident #54. Resident #39 reported facility staff were upset with her at the time for dumping water on another resident and she was instructed to next time use her call light.
Review of Resident #54's medical record revealed an admission dated of 02/21/17. Diagnoses includes anoxic brain damage, type two diabetes, irritability and anger, violent behavior, cognitive communication deficit, and unsteadiness on feet.
Review of the MDS assessment, dated 05/21/22, revealed the resident was severely cognitively impaired.
Review of Resident #54's progress note, dated 05/27/22 at 4:59 P.M., revealed the resident was intermittently wandering the unit and at times attempting to go into other resident rooms. One on one redirection and frequent toileting attempts with minimal success were attempted to prevent wandering into other rooms. Staff monitoring resident to attempt to prevent incident.
Interview on 06/28/22 at 3:19 P.M. with State Tested Nursing Assistant (STNA) #422 verified hearing about an incident between Resident #39 and Resident #54 about two to three weeks ago.
Interview on 06/28/22 at 3:26 P.M. with Resident #54 revealed the resident had no recollection of the incident.
Review of Self-Reported Incidents (SRI) for 2022 revealed no SRI had been initiated regarding a resident to resident altercation between Resident #39 and Resident #54.
Interview on 06/29/22 at approximately 12:00 P.M. with the Administrator and Registered Nurse (RN) Regional Nurse #456 verified they were aware of an interaction between Resident #39 and #54 on an unknown date when Resident #39 splashed water on Resident #54. RN Regional Nurse #456 reported the Director of Nursing (DON) called the Administrator who had called RN Regional Nurse #456. They determined a reported the residents were laughing about it and there was no intent to harm therefore an investigation was not completed.
Interview on 06/29/22 at 3:10 P.M. with Licensed Practical Nurse (LPN) #435 verified on 05/26/22 Resident #39 dumped approximately 120 cubic centimeter (cc) of water on Resident #54 after she would not leave her room and repeatedly stated she wanted a shower. LPN #435 reported water was observed on Resident #54 shirt near the waistband. LPN #435 reported neither resident was upset about the incident and Resident #39 laughed. LPN #435 stated she did believe it was a resident to resident incident and called the on-call manager to report the concern.
Review of policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, reviewed 02/2021, revealed the definition of abuse includes the willful infliction of intimidation or punishment with resulting physical harm, pain or mental anguish. It includes mental abuse. The definition of willful meant the individual must have acted deliberately, not that the individual intended to inflict injury or harm. Once the Administrator is notified an investigation of the allegation violation will be conducted.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview the facility failed to complete a baseline care plan with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview the facility failed to complete a baseline care plan with oxygen included as a focus for three residents, (#264, #34, and #213) out of five residents reviewed for baseline care plans. The current census is 58.
Findings include:
1. Record review of Resident #264 revealed the resident had been admitted to the facility on [DATE]. Diagnoses for Resident #264 include dementia with behaviors, diabetes, falls, neuralgia, and cognitive deficit.
Review of Resident #264's Minimum Data Set (MDS) assessment, dated 06/18/22, revealed the resident had impaired cognition and received supplemental oxygen.
Review of the physician orders dated 06/14/22 revealed the resident was to receive oxygen to maintain oxygen level above 90 percent.
Review of Resident #264's baseline care plans, dated 06/14/22, revealed no care plan for for oxygen. Per the care plans dated 06/26/22 the resident had a goal added to the 'basic needs' focus with the intervention of oxygen as ordered.
Interview on 06/28/22 at 3:14 P.M. with the Registered Nurse (RN) Regional Nurse #456 verified the use of oxygen was not addressed in the 06/14/22 baseline care plan.
Review of policy titled Comprehensive Care Plan/Baseline, revised October 2018, revealed a baseline care plan will be initiated within 48 hours of resident being admitted . The baseline care plan will be the temporary working care plan until the comprehensive care plan is completed.
2. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnosis included protein-calorie malnutrition, acute respiratory failure with hypoxia, weakness, cognitive communication deficit, osteoarthritis, hypertension, and Alzheimer's disease.
Review of the MDS assessment, dated 04/26/22, revealed the resident was cognitively impaired.
Review of Resident #34's record review revealed a baseline care plan had not been completed. The comprehensive care plan was initially completed on 02/25/22.
Interview on 06/30/22 at approximately 12:30 P.M. with RN Regional Nurse #456 verified a baseline care plan for Resident #34 could not be located.
3. Review of the medical record for Resident #213 revealed an admission date of 06/22/22. Diagnoses included chronic obstructive pulmonary disease, tracheostomy status, gastrostomy status, and dysphagia.
Review of the current physician orders revealed an order dated 06/22/22 for Resident #213 to have a #6 Shiley uncuffed tracheostomy (trach)in place to maintain patent airway, and to check every shift. Further review revealed an order dated 06/22/22 for Resident #213 to receive 30% cool aerosol via trach collar at bedside with oxygen 2 liters per minute via pressure line adapter.
Review of the baseline care plan dated 06/22/22 revealed no care plan for Resident #213's tracheostomy care or supplemental oxygen.
Interview on 06/28/22 at 5:06 P.M. with the Director of Nursing (DON) confirmed Resident #213's baseline care plan did not include care areas for the tracheostomy or supplemental oxygen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete comprehensive care plans for one (#34) out of 24 resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete comprehensive care plans for one (#34) out of 24 residents reviewed for care plans. The current census was 58.
Findings include:
Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnosis included protein-calorie malnutrition, acute respiratory failure with hypoxia, weakness, cognitive communication deficit, osteoarthritis, hypertension, and Alzheimer's disease.
Review of Resident #34's comprehensive care plan revealed it wasn't completed until 02/25/22.
Interview on 06/30/22 at approximately 12:30 P.M. with Registered Nurse Regional Nurse #456 verified Resident #34 was admitted on [DATE] and a comprehensive care plan was not initiated until 02/25/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, family interview, review of the facility policy, and staff interview, the facility f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, family interview, review of the facility policy, and staff interview, the facility failed to conduct care conferences with residents and their families. This affected two (#6 and #39) out of three residents reviewed for care conferences. The facility failed to revise a care plan following the assessment of one (#34) out of 24 residents reviewed for care plans. The current census was 58.
Findings include:
1. Review of the medical record of Resident #6 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic bronchitis, dementia with behaviors, heart disease, weakness, history of fractures, and depression.
Review of Resident #6's Minimum Data Set (MDS) assessment, dated 06/03/22, revealed the resident had impaired cognition and behavior, and was a two person assistance with Activities of Daily Living, (ADL).
Further review of Resident #6's medical records revealed there was no documentation of care conferences being conducted from 06/2021 through 06/2022.
Interview on 06/27/22 at 11:36 A.M. with Resident #6 and her daughter revealed the facility has not planned, conducted, or discussed the care of the resident with the resident and her daughter on a quarterly basis. Per Resident #6's daughter she attended care conferences last year but none were scheduled or offered in 2022. The resident's daughter stated she has requested care conferences with the staff but have the staff have not honored her request.
Interview on 06/29/22 at 4:00 P.M. with Licensed Social Worker (LSW) #408 verified there was no documentation in the Resident #6's record for care conferences having occurred. Per the social worker there had been no care conferences conducted with the team, the resident, and her family since 06/2021.
2. Review of Resident #39's medical record revealed an admission date of 07/11/19. Diagnoses included borderline personality disorder, type two diabetes mellitus, major depressive disorder, peripheral vascular disease, osteoarthritis, hyperlipidemia, insomnia, epilepsy, weakness, sleep apnea, lymphedema, and hypertension.
Review of the MDS assessment, dated 05/09/22, revealed the resident was cognitively intact.
Review of the care plan conferences revealed Resident #39 had not had a care plan conference since 07/02/20.
Interview on 06/29/22 at 4:24 P.M. with LSW #408 revealed on 06/29/22 she documented a care plan conference with Resident #39 that was held on 04/28/22. LSW #408 verified she has not planned or held formal care conferences in the past year with any residents. LSW #408 verified if it was not documented they were not complete.
3. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included protein-calorie malnutrition, acute respiratory failure with hypoxia, cognitive communication deficit, hyperlipidemia,, hypertension, restlessness and agitation, dementia, type two diabetes mellitus, and Alzheimer's disease.
Review of the MDS assessment, dated 04/26/22, revealed the resident was cognitively impaired. The assessment revealed there were no current pressure ulcers.
Review of the comprehensive care plan, initiated on 02/25/22, revealed a current care plan for pressure ulcers, including a stage three area on the coccyx.
Review of the medical record revealed, dated 03/17/22, revealed the pressure ulcer to the coccyx was resolved. The care plan was not updated to show the resolved area.
Interview on 06/28/22, at an unknown time, with Registered Nurse (RN) Regional Nurse #456 verified Resident #34's care plan had not been updated with the resolved pressure ulcer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview and record review, the facility failed to obtain orders for the flushing of a gastrostomy tube (g-tube) upon admission to the facility, failed to provide f...
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Based on resident interview, staff interview and record review, the facility failed to obtain orders for the flushing of a gastrostomy tube (g-tube) upon admission to the facility, failed to provide flushes as ordered by the physician, and failed to have a policy regarding g-tube care and treatment . This affected one (#213) of one resident reviewed for a g-tube. The facility census was 58.
Findings include:
Review of the medical record for Resident #213 revealed an admission date of 06/22/22 with diagnoses of chronic obstructive pulmonary disease, tracheostomy status, gastrostomy status, and dysphagia.
Review of physician orders upon admission revealed an order for an oral diet. There were no orders upon admission for g-tube flushes.
Review of a physician order dated 06/24/22 revealed Resident #213's g-tube should be flushed with 60 milliliters (mL) of water every eight hours to maintain patency.
Review of the treatment administration record (TAR) for Resident #213 revealed g-tube flushes were not given on 06/24/22 at 10:00 P.M., on 06/25/22 at 6:00 A.M., 2:00 P.M., and 10:00 P.M., on 06/26/22 at 6:00 A.M., on 06/27/22 at 2:00 P.M., on 06/28/22 at 2:00 P.M. and on 06/29/22 at 2:00 P.M.
Interview on 06/27/22 at 11:30 A.M. with Resident #213 revealed he had a g-tube but did not use it for nourishment or hydration.
The facility was unable to provide a policy regarding g-tube care or treatment.
Interview on 06/30/22 at 10:32 A.M., Assistant Director of Nursing (ADON) #446 confirmed the order for Resident #213's g-tube flushes started two days after admission. Further interview confirmed flushes were not documented on eight occasions and she could not provide verification the flushes were given on those occasions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on medical record review, observation, and staff interview, the facility failed to provide oxygen per physician order for one (#40) out of two residents reviewed for oxygen therapy. The current ...
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Based on medical record review, observation, and staff interview, the facility failed to provide oxygen per physician order for one (#40) out of two residents reviewed for oxygen therapy. The current census was 58.
Findings include:
Review of the medical record for Resident #40 revealed an admission date of 04/09/20 with medical diagnoses of dementia, paranoid personality disorder, and insomnia.
Review of the quarterly Minimum Data Set assessment, dated 05/09/22, revealed Resident #40 had severely impaired cognition, required extensive assistance of one person for bed mobility and transfers, and limited assistance of one person for toilet use and hygiene.
Review of a physician order dated 10/21/21 revealed Resident #40 received oxygen therapy at 2 liters per minute (L/min) per nasal cannula every shift as needed for dyspnea and respiratory distress.
Review of the medication administration record (MAR) for Resident #40 dated 06/27/22 through 06/29/22 revealed no documentation of the resident having any dyspnea or respiratory distress and no documentation oxygen was administered.
Observation on 06/27/22 at 2:49 P.M. revealed Resident #40 sitting in the common area receiving oxygen via nasal cannula at 3 L/min.
Interview on 06/27/22 at 3:04 P.M. with Licensed Practical Nurse (LPN) #457 confirmed Resident #40's oxygen was running at 3 L/min.
Interview on 06/27/22 at 5:40 P.M. with LPN #435 revealed a State Tested Nurse Aide (STNA) had applied Resident #40's oxygen and increased it above the physician's ordered rate. Further interview revealed STNAs should not adjust oxygen rates.
Observation on 06/28/22 at 9:55 A.M. revealed Resident #40 sitting in the common area receiving oxygen via nasal cannula at 2 L/min.
Observation on 06/29/22 at approximately 10:00 A.M. revealed Resident #40 sitting in the common area receiving oxygen via nasal cannula at 2 L/min.
Interview on 06/29/22 at 4:36 P.M. with LPN #410 confirmed Resident #40 had oxygen on earlier in the day on 06/29/22.
Interview on 06/30/22 at 10:23 A.M. with the Assistant Director of Nursing #446 confirmed Resident #40's MAR revealed no documentation oxygen was administered 06/27/22 through 06/29/22.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on staff interview and quarterly quality assessment and assurance (QAA) committee meetings, the facility failed to have a physician attend quarterly QAA committee meetings. This had the potentia...
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Based on staff interview and quarterly quality assessment and assurance (QAA) committee meetings, the facility failed to have a physician attend quarterly QAA committee meetings. This had the potential to affect all 58 residents in the facility.
Findings include:
Review of the sign-in sheets for the quarterly QAA meetings dated 07/27/21, 12/28/21, 03/29/22, and 06/29/22 revealed the physician was not present during the meetings on 07/27/21 and 12/28/21.
Interview on 06/30/22 at 3:52 P.M. with the Administrator confirmed the physician did not attend QAA meetings during the third and fourth quarters of 2021.
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record review and staff interview, the facility failed to transmit Minimum Data Set, (MDS) assess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record review and staff interview, the facility failed to transmit Minimum Data Set, (MDS) assessments for three (#266, #267, and #2) out of 24 residents reviewed for MDS assessments. The current census was 58.
Findings include:
1. Review of the medical record for Resident #266 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hip replacement, cancer, hypertension, and pressure ulcers. The resident was discharged from the facility in 03/2022.
Review of the MDS assessments revealed there was no discharged assessment transmitted in 03/2022 for Resident #266.
2. Record review for Resident #267 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #267 include heart disease, renal failure, and thyroid disease. The resident was discharged from the facility in 03/2022.
Review of the MDS assessments revealed there was no discharged assessment transmitted in 03/2022 for Resident #267.
2. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses include anemia, hypertension and diabetes. The resident was discharged from the facility in 03/2022.
Review of the MDS assessments revealed there was no discharged assessment transmitted in 03/2022 for Resident #2.
Interview on 06/28/22 at 2:00 P.M. with the Regional Nurse #456 verified the facility had not employed a MDS nurse since 03/2022. The Regional Nurse #456 verified the MDS assessments had not been completed and transmitted.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0730
(Tag F0730)
Minor procedural issue · This affected most or all residents
Based on staff interview and review of personnel files, the facility failed to ensure State Tested Nurse Aides (STNA) received annual in-services. This affected two (STNA #401 and STNA #414) our of 18...
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Based on staff interview and review of personnel files, the facility failed to ensure State Tested Nurse Aides (STNA) received annual in-services. This affected two (STNA #401 and STNA #414) our of 18 STNAs employeed and had the potential to affect all 58 residents residing in the facility.
Findings include:
Review of the personnel files for STNA #401 revealed a hire date of 06/24/13. There was no evidence of the completion of 12 hours of in-services every 12 months.
Review of the personnel files for STNA #414 revealed a hire date of 04/21/04. There was no evidence of the completion of 12 hours of in-services every 12 months.
Interview on 06/30/22 at 1:30 P.M. with the Director of Human Resources confirmed the STNAs had not completed 12 hours of in-services over the last 12 months.
Jul 2019
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's policy, the facility failed to implement the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's policy, the facility failed to implement the facility policy for investigating and reporting an injury of unknown origin. This affected one (#56) of one resident reviewed for injury of unknown origin. The census was 72.
Findings include:
Review of the medical record for Resident #56 revealed an admission date of 04/11/18. Diagnoses included hemiplegia, hemiparesis, dementia and anxiety.
Review of the physician's orders revealed an order dated 02/14/19 to perform weekly skin checks with showers.
Review of the Minimum Data Set assessment dated [DATE] revealed Resident #56 was assessed as being cognitively moderately impaired and for skin issues had moisture associated skin damage. The resident also is a tube feed and does not receive any food by mouth.
Review of the plan of care dated 03/22/19 for Resident #56 revealed a plan for being at risk for impaired skin integrity due to cerebrovascular accident with hemiplegia. The intervention included to monitor skin during baths and weekly.
Review of the skin evaluations dated 07/01/19 at 2:00 P.M., revealed a skin condition, type ecchymosis treatment and monitor blisters for drainage. The medical chart was absent of any other skin evaluations.
Review of nurses note dated 07/01/19 at 2:34 P.M., revealed Resident #56 has five fluid filled blisters noted to right hand on fingers with three red spots noted to right forearm.
Review of physician's progress notes dated 07/02/19 at 11:00 A.M., revealed Resident #56 has fluid filled blisters on the right hand fingers. Also, has a few bumps on the right arm. Physician orders revealed orders for a rash on the arm was consistent with insect bites, to monitor and blisters are unknown cause and to monitor.
Interview with the Director of Nursing #1 on 07/24/19 at 1:00 P.M., verified the origin of the blisters were unknown, there was no investigation and the injury was not reported to the state.
Review of the facility's policy titled Abuse, Mistreatment, neglect, Exploitation and Misappropriation of Resident Property dated 12/11/17, revealed it is the facility's policy to investigate all alleged violations involving Abuse, neglect, Misappropriation of Residents Property, Exploitation, or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who report such incidents and all allegations are free from retaliation or reprisal for reporting this incident. Injury of unknown source is an injury is classified as an Injury of Unknown Source when both of the following conditions are met. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular time, or the incident of injuries over time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's policy, the facility failed to report an injury of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's policy, the facility failed to report an injury of unknown injury to the state agency. This affected one (#56) of one resident reviewed for injury of unknown origin. The census was 72.
Findings include:
Review of the medical record for Resident #56 revealed an admission date of 04/11/18. Diagnoses included hemiplegia, hemiparesis, dementia and anxiety.
Review of the physician's orders revealed an order dated 02/14/19 to perform weekly skin checks with showers.
Review of the Minimum Data Set assessment dated [DATE] revealed Resident #56 was assessed as being cognitively moderately impaired and for skin issues had moisture associated skin damage. The resident also is a tube feed and does not receive any food by mouth.
Review of the plan of care dated 03/22/19 for Resident #56 revealed a plan for being at risk for impaired skin integrity due to cerebrovascular accident with hemiplegia. The intervention included to monitor skin during baths and weekly.
Review of the skin evaluations dated 07/01/19 at 2:00 P.M., revealed a skin condition, type ecchymosis treatment and monitor blisters for drainage. The medical chart was absent of any other skin evaluations.
Review of nurses note dated 07/01/19 at 2:34 P.M., revealed Resident #56 has five fluid filled blisters noted to right hand on fingers with three red spots noted to right forearm.
Review of physician's progress notes dated 07/02/19 at 11:00 A.M., revealed Resident #56 has fluid filled blisters on the right hand fingers. Also, has a few bumps on the right arm. Physician orders revealed orders for a rash on the arm was consistent with insect bites, to monitor and blisters are unknown cause and to monitor.
Interview with the Director of Nursing #1 on 07/24/19 at 1:00 P.M., verified the origin of the blisters were unknown, there was no investigation and the injury was not reported to the state.
Review of the facility's policy titled Abuse, Mistreatment, neglect, Exploitation and Misappropriation of Resident Property dated 12/11/17, revealed it is the facility's policy to investigate all alleged violations involving Abuse, neglect, Misappropriation of Residents Property, Exploitation, or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who report such incidents and all allegations are free from retaliation or reprisal for reporting this incident. Injury of unknown source is an injury is classified as an Injury of Unknown Source when both of the following conditions are met. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular time, or the incident of injuries over time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's policy, the facility failed investigate an injury o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's policy, the facility failed investigate an injury of unknown origin. This affected one (#56) of one resident reviewed for injury of unknown origin. The census was 72.
Findings include:
Review of the medical record for Resident #56 revealed an admission date of 04/11/18. Diagnoses included hemiplegia, hemiparesis, dementia and anxiety.
Review of the physician's orders revealed an order dated 02/14/19 to perform weekly skin checks with showers.
Review of the Minimum Data Set assessment dated [DATE] revealed Resident #56 was assessed as being cognitively moderately impaired and for skin issues had moisture associated skin damage. The resident also is a tube feed and does not receive any food by mouth.
Review of the plan of care dated 03/22/19 for Resident #56 revealed a plan for being at risk for impaired skin integrity due to cerebrovascular accident with hemiplegia. The intervention included to monitor skin during baths and weekly.
Review of the skin evaluations dated 07/01/19 at 2:00 P.M., revealed a skin condition, type ecchymosis treatment and monitor blisters for drainage. The medical chart was absent of any other skin evaluations.
Review of nurses note dated 07/01/19 at 2:34 P.M., revealed Resident #56 has five fluid filled blisters noted to right hand on fingers with three red spots noted to right forearm.
Review of physician's progress notes dated 07/02/19 at 11:00 A.M., revealed Resident #56 has fluid filled blisters on the right hand fingers. Also, has a few bumps on the right arm. Physician orders revealed orders for a rash on the arm was consistent with insect bites, to monitor and blisters are unknown cause and to monitor.
Interview with the Director of Nursing #1 on 07/24/19 at 1:00 P.M., verified the origin of the blisters were unknown, there was no investigation and the injury was not reported to the state.
Review of the facility's policy titled Abuse, Mistreatment, neglect, Exploitation and Misappropriation of Resident Property dated 12/11/17, revealed it is the facility's policy to investigate all alleged violations involving Abuse, neglect, Misappropriation of Residents Property, Exploitation, or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who report such incidents and all allegations are free from retaliation or reprisal for reporting this incident. Injury of unknown source is an injury is classified as an Injury of Unknown Source when both of the following conditions are met. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular time, or the incident of injuries over time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the ombudsman when residents were transferred ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the ombudsman when residents were transferred or discharged from the facility. This affected two (#67 and #51) of four reviewed for hospitalization and discharge. The facility identified 64 residents who were transferred or discharged from the facility since 04/01/19. The census was 72.
Findings include:
1. Review of the medical record for Resident #67 revealed an admission date of 07/03/14. Diagnoses include Dementia, Parkinson's disease and Schizophrenic.
Review of the Lutheran Homes Society -[NAME] Campus, Bed Hold and leave notices dated 07/24/14 for Resident #67 representative which acknowledged they did not want a bed hold, this is the only paper which has been signed.
Review of the nurse notes on 06/07/19 at 4:00 P.M. revealed Resident #67 was sent out to the hospital for evaluation per doctor for acute onset of weakness, tachycardia and unresponsiveness.
Interview with Social Services #250 on 07/25/19 at 1:02 P.M. verified there are no notifications to the ombudsman of discharges of any kind but will start doing this going forward.
2. Review of Resident #51's medical record revealed an admission date of 05/10/19. Diagnoses included acute kidney failure, chronic kidney disease, heart failure, diabetes mellitus type II, chronic obstructive pulmonary disease, and major depression.
Review of a transfer notice dated 06/20/19 revealed Resident #51 was sent to the emergency room due to a change in physical condition.
Review of Resident #51's paper and electronic medical record revealed no evidence of a notice sent to the ombudsman of Resident #51's transfer to the hospital.
Interview on 07/25/19 at 12:58 P.M. with Licensed Social Worker #250 stated she had not been sending a list of residents transferred or discharged to the ombudsman, and verified the ombudsman was not notified of Resident #51's transfer on 06/20/19.
Review of the facility policy titled Bed Hold and Leave of Absence revised date 02/09 revealed the purpose of the Lutheran Home society policy on admissions to its Medicare and Medicaid certified nursing facility is to establish uniform guidelines for facility staff to follow when resident leave the facility for hospitalizations or therapeutic leave. This policy was absent of language for the facility to contact the Ombudsman of all discharges.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure bed hold notice...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure bed hold notice was given to the resident or representative of transfer to the hospital. This affected one (#67) of four residents reviewed for hospitalization and discharge. The facility identified 64 residents who were transferred or discharged from the facility since 04/01/19. The census was 72.
Findings include:
Review of the medical record for Resident #67 revealed an admission date of 07/03/14. Diagnoses include Dementia, Parkinson's disease and Schizophrenic.
Review of the Lutheran Homes Society -[NAME] Campus , Bed Hold and Leave notices upon admission dated 07/24/14 for Resident #57 was signed by the representative which acknowledged they did not want a bed hold and this is the only paper which has been signed.
Review of the nurse notes on 06/07/19 at 4:00 P.M., revealed Resident #67 was sent out to the hospital for evaluation per doctor for acute onset of weakness, tachycardia and unresponsiveness.
Interview with Admissions Director Liaison #260 on 07/25/19 at 12:40 P.M., verified there was not a bed hold notice given to Resident #67 upon discharge to the hospital. He had signed a paper upon admission he did not want a bed hold but was unaware he needed to receive another one when being sent to the hospital. Did not receive the document which is the policy for bed hold.
Review of the facility's Bed Hold and Leave of Absence policy revised 02/09 the purpose of the Lutheran home society policy on admissions to its Medicare and Medicaid certified nursing facility is to establish uniform guidelines for facility staff to follow when resident leave the facility for hospitalizations or therapeutic leave. Under section B states at the time of transfer of a resident for hospitalization or therapeutic leave, the resident will be provided with a separate bed hold notice summarizing the facility's bed hold policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to update a care plan when a pressure reducing intervent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to update a care plan when a pressure reducing intervention was discontinued. This affected one (#37) of three residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. The census was 72.
Findings include:
Review of Resident #37's medical record revealed an admission of 03/30/19. Diagnoses included dysphagia, unspecified visual loss, umbilical hernia, essential hypertension, hyperlipidemia, and chronic bronchitis.
Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was severely cognitively impaired and was assessed with one unstageable (a localized area of tissue necrosis and can be covered by slough or eschar) pressure ulcer that was present on admission or re-entry to the facility.
Review of a skin integrity care plan dated 03/30/19 revealed an intervention for Resident #37 to have pressure relieving boots on at all times except during transfers and therapy.
Observations on 07/23/19 at 1:33 P.M. and 3:46 P.M., on 07/24/19 at 7:38 A.M., at 10:06 A.M., and at 1:21 P.M. revealed Resident #37 sitting in a reclining chair in her bedroom or in the common area with no pressure relieving boots on.
Review of a nursing progress note dated 04/15/19 revealed an occupational therapist spoke to the assistant director of nursing about the risks and benefits of Resident #37's pressure relieving boots. Further review of the nursing progress note revealed Resident #37's pressure relieving boots were discontinued.
Review of Resident #37's July 2019 physician orders revealed no order for pressure relieving boots.
Interview on 07/24/19 at 4:39 P.M. with Licensed Practical Nurse (LPN) #460, verified Resident #37 had no order for pressure relieving boots, and also verified Resident #37 had not been wearing any pressure relieving boots. LPN #460 verified Resident #37's pressure relieving boots were discontinued on 04/16/19, but remained and intervention on the skin integrity care plan. LPN #460 verified the intervention should have been removed from the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the monitoring of blisters and bug bites on re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the monitoring of blisters and bug bites on resident was monitored per physician's order. This affected one (#56) of one reviewed for skin conditions. The census was 72.
Findings include:
Review of the medical record for Resident #56 revealed an admission date of 04/11/18. Diagnoses included hemiplegia, hemiparesis, dementia and anxiety.
Review of the physician's orders revealed an order dated 02/14/19 to perform weekly skin checks with showers.
Review of the Minimum Data Set assessment dated [DATE] revealed Resident #56 was assessed as being cognitively moderately impaired and for skin issues had moisture associated skin damage. The resident also is a tube feed and does not receive any food by mouth.
Review of the plan of care dated 03/22/19 for Resident #56 revealed a plan for being at risk for impaired skin integrity due to cerebrovascular accident with hemiplegia. The intervention included to monitor skin during baths and weekly.
Review of the skin evaluations dated 07/01/19 at 2:00 P.M., revealed a skin condition, type ecchymosis treatment and monitor blisters for drainage. The medical chart was absent of any other skin evaluations.
Review of nurses note dated 07/01/19 at 2:34 P.M., revealed Resident #56 has five fluid filled blisters noted to right hand on fingers with three red spots noted to right forearm.
Review of physician's progress notes dated 07/02/19 at 11:00 A.M., revealed Resident #56 has fluid filled blisters on the right hand fingers. Also, has a few bumps on the right arm. Physician orders revealed orders for a rash on the arm was consistent with insect bites, to monitor and blisters are unknown cause and to monitor.
Interview with the Director of Nursing #1 on 07/24/19 at 1:00 P.M., verified there was no documentation of monitoring of the blisters or bug bites. She said the nurse aides do the skin assessments on shower days but was not able to produce evidence this occurred.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facilty policy review and staff interview, the facility failed to implement a press...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facilty policy review and staff interview, the facility failed to implement a pressure reducing device to prevent pressure ulcers for a resident with a history of pressure sores. This affected one (#37) of three residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. The census was 72.
Findings include:
Review of Resident #37's medical record revealed an admission of 03/30/19. Diagnoses included dysphagia, unspecified visual loss, umbilical hernia, essential hypertension, hyperlipidemia, and chronic bronchitis.
Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was severely cognitively impaired, required extensive assistance with bed mobility, and was assessed with one unstageable (a localized area of tissue necrosis and can be covered by slough or eschar) pressure ulcer that was present on admission or re-entry to the facility.
Review of a physician order dated 04/02/19 revealed Resident #37 was ordered a pressure reducing cushion to her wheelchair and recliner and staff should check placement each shift.
Review of a wound assessments dated between 03/30/19 and 07/24/19 revealed Resident #37 was admitted to the facility with an unstageable pressure ulcer to her left heel on 03/30/19 that was monitored by staff weekly. Resident #37 did not have a pressure ulcer to her buttocks or coccyx during this time frame.
Observations on 07/23/19 at 1:33 P.M. and 3:46 P.M., on 07/24/19 at 7:38 A.M., at 10:06 A.M., and at 1:21 P.M. revealed Resident #37 sitting in a reclining chair in her bedroom or in the common area with no pressure reducing cushion in place.
Observation and interview on 07/24/19 at 4:37 P.M., with Licensed Practical Nurse (LPN) #460, revealed Resident #37 sitting in her reclining chair in her bedroom with no pressure cushion in place. LPN #460 verified Resident #37 should have a pressure cushion in her recliner.
An observation of Resident #37's coccyx was attempted on 07/25/19 at 6:54 A.M., however, Resident #37 was very confused, fearful, and suspicious of staff. When asked if an observation could be made later, Resident #37 appear agitated and more suspicious, asking to see staff member's identification badges. Resident #37 refused an observation of her coccyx.
Review of a facility policy titled, Skin Care and Wound Treatment Protocol, dated January 2016, revealed preventative measures to utilize include positioning devices such as pillows, cushions, and overlays in beds and chairs as indicated to relieve pressure on bony area.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and medical record review, the facility to ensure fall interventions were in place as ordered and care planned. This affected one (#51) of two residents reviewed...
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Based on observation, staff interview, and medical record review, the facility to ensure fall interventions were in place as ordered and care planned. This affected one (#51) of two residents reviewed for falls. The facility identified six residents with orders for pressure pad alarms as fall interventions. The census was 72.
Findings include:
Review of Resident #51's medical record revealed an admission date of 05/10/19. Diagnoses included acute kidney failure, chronic kidney disease, heart failure, diabetes mellitus type II, chronic obstructive pulmonary disease, and major depression.
Review of the most recently completed Minimum Data Set (MDS) assessment completed 06/09/19 revealed Resident #51 was severely cognitively impaired and was assessed as requiring limited assistance with bed mobility, transfers, and walking in the room and corridor.
Review of a physician order dated 07/05/19 revealed Resident #51 was ordered a pressure pad alarm to the recliner and staff was to check placement and function every shift.
Review of a fall care plan dated 07/05/19 revealed Resident #51 had an intervention to have a pressure pad alarm to Resident #51's reclining chair.
Observation on 07/24/19 at 8:50 A.M. revealed Resident #51 sitting in his wheelchair in the therapy room receiving therapy services. Observation on 07/24/19 at approximately 10:00 A.M. revealed therapy staff members assisting Resident #51 back to his room by pushing his wheelchair. Observation on 07/24/19 at 10:05 A.M., revealed Resident #51 sitting in his reclining chair in his bedroom and was free from distress. Further observation in Resident #51's bedroom revealed Resident #51's pressure pad alarm was still applied to the wheelchair he returned to his bedroom with from therapy. Resident #51 was alone in his bedroom and not other alarming devices were on his recliner.
Interview on 07/24/19 at 10:21 A.M. with Licensed Practical Nurse (LPN) #460 stated Resident #51 was not safe to be up and walking in his room by himself because he was not strong enough and was a fall risk. LPN #460 verified Resident #51 was ordered to have a pressure pad alarm to his recliner.
Observation and interview on 07/24/19 at 10:25 A.M., with LPN #460, revealed Resident #51 sitting in his reclining chair with no pressure pad alarm in place. LPN #460 verified Resident #51 should have a pressure pad alarm to his chair, and verified the alarm device was still on Resident #51's wheelchair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and medical record review, the facility to ensure a urinary catheter was maintained in a manner to prevent contamination. This affected one (#51) of one resident...
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Based on observation, staff interview, and medical record review, the facility to ensure a urinary catheter was maintained in a manner to prevent contamination. This affected one (#51) of one residents reviewed for urinary catheters. The facility identified four residents with urinary catheters. The census was 72.
Findings include:
Review of Resident #51's medical record revealed an admission date of 05/10/19. Diagnoses included acute kidney failure, chronic kidney disease, heart failure, diabetes mellitus type II, chronic obstructive pulmonary disease, and major depression.
Review of Resident #51's July 2019 medication orders revealed he was not currently prescribed an antibiotic, and review of nursing progress notes between 07/05/19 and 07/24/19 revealed Resident #51 had no recent urinary tract infections.
Observation on 07/23/19 at 3:42 P.M., revealed Resident #51 sitting in his reclining chair with his eyes closed. Further observation revealed Resident #51's urinary catheter collection bad was laying flat on the floor in direct contact with the tile floor and was noted to have a small plastic garbage can laying on top of the urinary catheter collection bag.
Observation on 07/24/19 at 7:38 A.M., revealed Resident #51 sitting in his reclining chair with his urinary catheter collection bag hanging from a small trash can in his room. The trash can contained soiled disposable rubber gloves, a face mask, and an empty oxygen concentrator humidification container. The bottom of urinary catheter collection back was also noted to be resting on the floor. Observation on 07/24/19 at 10:05 A.M., revealed Resident #51 sitting in his room in his recliner, after returning from the therapy room, and the urinary catheter collection bag was, again, observed hanging from the trash can and resting on the floor.
Observation and interview on 07/24/19 at 10:25 A.M., with LPN #460, revealed Resident #51 sitting in his reclining chair with his urinary catheter collection bag hanging from the trash can and resting on the floor. LPN #460 verified Resident #51's urinary catheter collection bag should be hung from a clean surface and off the floor to prevent infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on review of facility staffing tools, nursing schedules, and and staff interview, the facility failed to ensure a registered nurse (RN) was on duty at least eight consecutive hours a day, seven ...
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Based on review of facility staffing tools, nursing schedules, and and staff interview, the facility failed to ensure a registered nurse (RN) was on duty at least eight consecutive hours a day, seven days a week. This affected 72 of 72 residents residing in the facility.
Findings include:
Review of facility staffing tool documents dated 07/19/19, 07/20/19, and 07/21/19, revealed the facility did not have a RN on duty during the on the 7:00 A.M. to 7:30 P.M. shift or the 7:00 P.M. to 7:30 A.M. shift.
Review of nurse staffing schedules provided by the facility dated 07/19/19, 07/20/19, and 07/21/19 revealed the facility did not have an RN on duty on any shift during the three days.
Interview on 07/25/19 at approximately 12:30 P.M., with Director of Nursing (DON) #1 verified the facility did not have an RN on duty on any shift on 07/19/19, 07/20/19, and 07/21/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on employee personnel file review, staff interview, and review of facility policy, the facility failed to ensure state tested nurse aides (STNA) were provided with at least 12 hours of annual in...
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Based on employee personnel file review, staff interview, and review of facility policy, the facility failed to ensure state tested nurse aides (STNA) were provided with at least 12 hours of annual in-service training. This affected two (#500 and #501) nurse aide employee files reviewed. This deficient practice had the potential to affect 72 of 72 residing in the facility. The census was 72.
Findings include:
1. Review of STNA #500's personnel file revealed a hire date of 05/19/16. Further review of the employee file revealed STNA #500 had not had 12 hours of in-servicing in the last year.
2. Review of STNA #501's personnel file revealed a hire date of 03/16/17. Further review of the employee file revealed STNA #501 had not had 12 hours of in-servicing in the last year.
Interview on 07/25/19 at 3:31 P.M. with Director of Human Resources #502 verified STNA #500 and STNA #501 did not have 12 hours of annual in-service training.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure cor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure correct doses of medications were available for residents, and failed to administer medications per physician orders. This affected one (#44) of five residents reviewed for unnecessary medications. The facility identified 40 residents who received antidepressant medications in the facility. The census was 72.
Findings include:
Review of Resident #44's medical record revealed an admission date of 10/11/16. Diagnoses included unspecified dementia without behavioral disturbances, unspecified psychosis, chronic kidney disease, major depression, anxiety, and diabetes mellitus type II.
Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] MDS revealed Resident #44 had short term and long term memory problems, and severely impaired cognitive skills for daily decision making. Resident #44 was assessed with no behaviors in the look-back period of the assessment.
Review of a physician order dated 07/10/19 revealed Resident #44 was ordered the antidepressant Remeron 30 milligrams (mg) by mouth every night at bedtime for depression.
Review of a medication administration record (MAR) from July 2019 revealed facility nurses were documenting Resident #44 received Remeron 30 mg by mouth at bedtime between 07/10/19 through 07/23/19.
Observation on 07/24/19 at 2:00 P.M., with Licensed Practical Nurse (LPN) #460, revealed Resident #44's medications in the medication cart from the facility pharmacy. Further observation inside the medication cart revealed a plastic pre-packaged pouch with Resident #44's name and printing on the outside of the pouch indicated the contents inside was a Remeron 7.5 mg tablet. Observation of the inside contents of the package revealed one Remeron 7.5 mg tablet which was to be administered on 07/24/19 at bedtime.
Interview on 07/24/19 at 2:10 P.M. with LPN #460 verified Resident #44 should be receiving Remeron 30 mg by mouth at bedtime and only had 7.5 mg available.
Interview on 07/24/19 at 2;15 P.M. with Director of Nursing (DON) #1 stated there was confusion with Resident #44's previous Remeron order, and after a conversation with the physician and the pharmacy, the order was corrected on 07/10/19 for Resident #44 to receive Remeron 30 mg by mouth at bedtime everyday. DON #1 stated the facility pharmacy kept sending Remeron 7.5 mg tablets that facility nurses were administering to Resident #44 at bedtime. DON #1 verified Resident #44 was not receiving her correct dose of Remeron since 07/10/19. DON #1 stated the facility had been having issues with the facility pharmacy and were actively seeking a new pharmacy to supply medications for facility residents.
Observations on 07/23/19 at 2:06 P.M. and 3:48 P.M., on 07/24/19 at 7:32 A.M., at 8:52 A.M., at 10:07 A.M., and at 1:23 P.M., and on 07/25/19 at 7:21 A.M., revealed Resident #44 did not display any signs of increased depression or any acute changes to her physical or mental condition.
Review of a hospice note dated 07/18/19 revealed no documentation of Resident #44 displaying any changes in mood or worsening depression.
Review of a facility policy titled, Automated Dispensing Unit for Routine Medication Administration, dated December 2017, revealed the facility may use an automated dispensing unit (ADU) for routine administration, where permitted by regulation or law. ADUs may be used by authorized facility staff and contents are property of the pharmacy. New medication orders received by the nurse are transmitted to the pharmacist, and after review and authorization of the order, the medication is made available for the ADU to dispense when needed next. The nurse then accesses the medications for the time needed and initiates the dispensing of all authorized medications by the dispensing unit. When the packaging process is complete, the nurse checks the packaged drugs, secures the room, and stores any medications not needed immediately in the medication cart.
Review of a facility policy titled, Medication Administration, revised May 2019, revealed prescribed medications are ordered and delivered in a timely fashion to residents. The five rights (resident, drug, dose, route, and time) to medication delivery will be followed for all medication passes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure monthly pharmacy...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure monthly pharmacy review irregularities were reviewed by the physician. This affected one (#25) of five residents reviewed for unnecessary medications. The facility census was 72.
Findings include:
Review of Resident #25's medical record revealed an admission date of 06/30/17. Medical diagnoses included Parkinson's disease, dementia with behaviors, hypertension, anxiety disorder, major depressive disorder, syncope and collapse, dysphagia, and generalized weakness.
Review of the resident's Minimum Data Set assessment dated [DATE] revealed no impairment in cognition. The resident received antipsychotic, antianxiety, antidepressant, and opioid medication.
Review of the resident's monthly pharmacy reviews revealed recommendations were made to the physician in July 2018, December 2018, January 2019, and February 2019. Further review of the resident's medical record revealed no indication what the recommendations were or that the physician had ever responded to the recommendations.
Interview with the Director of Nursing on 07/24/19 at 10:03 A.M., verified the pharmacist made recommendations in July 2018, December 2018, January 2019, and February 2019 and the facility had no record of what the recommendations were. She stated she spoke with the pharmacist and he was not able to provide them to the facility. She verified there was no documentation from the physician indicating a response to the pharmacy recommendations.
Review of a facility policy titled Medication Regimen Review dated 12/17 revealed resident medication irregularities are documented in the resident's active record and reported to the Director of Nursing, attending physician, and the medical director. Recommendations are acted upon and documented on by the facility staff and/or the prescriber.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident's as ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident's as needed (PRN) antianxiety medication was time limited. This affected one (#25) of five residents reviewed for unnecessary medications. The facility identified 14 residents on antianxiety medications. The facility census was 72.
Findings include:
Review of Resident #25's medical record revealed an admission date of 06/30/17. Medical diagnoses included Parkinson's disease, dementia with behaviors, hypertension, anxiety disorder, major depressive disorder, syncope and collapse, dysphagia, and generalized weakness.
Review of the resident's Minimum Data Set assessment dated [DATE] revealed no impairment in cognition. The resident received antianxiety medication.
Review of the resident's physician's orders revealed an order dated 11/13/18 for Ativan (antianxiety medication) 0.5 milligrams (mg) twice daily as needed (PRN) for anxiety. Review of the resident's Medication Administration Record revealed she received the Ativan one time in June and three times in July.
Interview with Regional Clinical Director #210 on 07/25/19 at 2:20 P.M. verified the resident had a PRN Ativan order since 11/13/18. She verified there was no stop date and no rationale for extending its use.
Review of a facility policy titled Antipsychotic/Psychotropic Medication and GDRs revised on 01/19 revealed PRN psychotropic drug orders are limited to 14 days. The attending physician/nurse practitioner, if appropriate may extend the PRN order beyond 14 days; but should document their rationale in the resident's medical record and indicate the duration for the PRN order.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, and review of facility policies, the facility failed to ensure the ice machine was maintained in a sanitary manner. This had the potential to affect all resident...
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Based on observation, staff interview, and review of facility policies, the facility failed to ensure the ice machine was maintained in a sanitary manner. This had the potential to affect all residents except two (Residents #10 and #56) who the facility identified as not receiving any food by mouth (NPO). The facility census was 72.
Findings include:
Observation of the facility kitchen on 07/22/19 at 9:13 A.M., revealed the bin type ice machine contained a layer of black colored debris, which appeared to be mold, across the inside top of the ice machine. The interior sides of the ice machine contained a grayish-white lime-like substance.
Interview and observation with Dietary Manager #220 at the time of the above observation verified these findings. She stated the maintenance department was responsible for sanitizing the ice machine. She was unable to state when the ice machine had been cleaned last. She stated it should be cleaned twice weekly.
Further interview with Dietary Manager #220 on 07/24/19 at 11:54 A.M., verified the facility had no documentation indicating the ice machine had ever been deep cleaned. She stated they had called an outside company to schedule this service.
Review of a facility policy titled Production, Storage, and Dispensing of Ice revised on 01/01/19 revealed ice will be produced, stored and dispensed in a manner to avoid contamination. The ice dispenser will be cleaned and sanitized. Inside and outside of machine and the area around the machine will be cleaned.
Review of a facility policy titled Cleaning Instructions: Ice Machine and Equipment revised 01/01/19 revealed ice machine and equipment will be cleaned and sanitized on a regular basis. Procedures included unplug the ice machine and remove the ice. Wash the interior thoroughly using a detergent solution. Rinse and drain the interior with clean hot tap water. Sanitize. Air dry.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Legionella and waterborne illness prevention documentation and staff interview, the facility f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Legionella and waterborne illness prevention documentation and staff interview, the facility failed to implement a legionella control plan with identified control measures and documentation. This had the ability to affect 72 of 72 residents residing in the facility. The census was 72.
Findings include:
Review of a facility policy titled Legionella dated [DATE] revealed the facility would proactively maintain water systems within the facility against the bacterium Legionella and other water-borne pathogens. The facility would specify protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained.
Further review of the facility Legionella risk management documentation revealed no flow sheet indicating potential risk areas in the facility. The facility indicated their water temperatures were normally above or below the temperature Legionella grows best (77 to 108 degrees) and stated temperature checks were periodically taken to verify temperature. The risk management documentation also indicated Legionella growth may be affected by water laying dormant in lines and changing temperature due to low census and short term shutdown of resident room wings or corridors. Any time a wing is unoccupied and then readied for reoccupation, special care will be given to the hot and cold water systems in the affected rooms, including flushing lines and monitoring water temperatures prior to reoccupancy.
Interview with Maintenance Director #200 on [DATE] at 3:32 P.M. verified the facility did
not have a flowsheet indicating what areas of concern should be monitored. He verified the facility had not implemented control measures to monitor for legionella and other waterborne illnesses other than the monitoring of temperatures in resident rooms for temperatures within the required 105-120 degrees. He stated the facility did not have a water management team established. He verified the facility had rooms that were not in use and eyewash stations and an ice machine that could be potential risk areas. He had no documentation of control measures for these areas.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0838
(Tag F0838)
Minor procedural issue · This affected most or all residents
Based on facility assessment review and staff interview, the facility failed to include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are ...
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Based on facility assessment review and staff interview, the facility failed to include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet the residents' needs. This deficient practice had potential to affect 72 of 72 residents residing in the facility. The census was 72.
Findings include:
Review of the facility assessment from 2019 revealed no documentation of the facility evaluating the staff needed to ensure sufficient number of qualified staff are available to meet each resident's need. The assessment failed to include the knowledge and skills required of staff to maintain the highest resident well-being and current professional standards of practice based on a competency-based approach, and did not address individual staff assignments and systems for coordination and continuity of care.
Interview on 07/25/19 at 2:34 P.M. with Administrator #2 verified the facility assessment did not include an evaluation of facility staffing needs and staffing knowledge and skills.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Ohio facilities.
Concerns
- • 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Lutheran Home's CMS Rating?
CMS assigns LUTHERAN HOME an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Ohio, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Lutheran Home Staffed?
CMS rates LUTHERAN HOME's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Ohio average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Lutheran Home?
State health inspectors documented 41 deficiencies at LUTHERAN HOME during 2019 to 2024. These included: 37 with potential for harm and 4 minor or isolated issues.
Who Owns and Operates Lutheran Home?
LUTHERAN HOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 54 certified beds and approximately 27 residents (about 50% occupancy), it is a smaller facility located in NAPOLEON, Ohio.
How Does Lutheran Home Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, LUTHERAN HOME's overall rating (4 stars) is above the state average of 3.2, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Lutheran Home?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Lutheran Home Safe?
Based on CMS inspection data, LUTHERAN HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Lutheran Home Stick Around?
Staff turnover at LUTHERAN HOME is high. At 60%, the facility is 14 percentage points above the Ohio average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Lutheran Home Ever Fined?
LUTHERAN HOME has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Lutheran Home on Any Federal Watch List?
LUTHERAN HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.